1. COMPLEX NEEDS OF YOUNG DRUG USERS & OUR TREATMENT RESPONSE
National Drug Treatment Centre Board Conference
Dublin, November 16/17th, 2006
Dr. Gerry McCarney

2. Complex needs of young drug users and our treatment response
A look at the needs of young people
Drug use in adolescence
Why treat now?
Principles of development and delivery
How we are responding to this need in an Irish context – service model
Special needs / vulnerable groups

3. review of early clients
86 consecutive clients, 54/46 - female : male
Adolescent age range 14-18, mean 16.8 yrs
Drug history -Opiate users +/- other drug use
1st drug use age 12 , 14.7
Daily opiate use 12/12
Polydrug use 60%, inc. street methadone (78%)
IVDA hx. 59% (33% currently), 64% not tested
Study carried out by Dr.John Fagan et al-
Fagan, Smyth & Naughton.

4. YPP- study findings cont’d
58% living with parents
30% homeless!
(half in hostels)
9% partner
48% had been homeless
27% in care before
51% has SW input
Left boys earlier
14% expelled, 50% dropped out
37% had work history

5. YPP- study findings
52% in relationship, 45% overall had a heroin using partner
45% hx. sibling opiate, 58% parental EtOH
48% convicted, 31% prison, 38% charges
52% saw psych., 11% admitted, 33% DSH
BOYS earlier to leave school, use heroin, be in care,+ family hx.
GIRLS-more likely to have relationship with user

6. What this says.. attendees at YPP exhibit a history of:
Early drug use progressing to daily use
Have early care disruption/chaos
+ family history of substance misuse
Use many drugs, many IVDA not tested
Significant forensic involvement
Significant co-morbidity
Multi agency integration approach required

7. Maslow’s Hierarchy of Need
Help me , I cannot stop using!
Every Child Matters 2004 – 5 outcomes mirror Maslow- being healthy, staying safe, enjoying & achieving, making a positive contribution, economic wellbeing. Norwood- coping information, rest left unattended. Then helping information, etc, enlightening, empowering , and so on.Level 1- breathe, eat, sleep. 2- safety, health, belongings. 3- friendship, sexual intimacy, communication. 4- self respect, respect from others, confidence, competence.
The ‘need’ to use drugs can override all of the above

8. Needs of young drug misusers
Physical- shelter, food, clothes,
Safety- from adults, peers, society, drugs
Belonging- need for love-family attachment, communication, contact from others, non-judgemental care,
Self-esteem- esteem, self concept, negative self view, anxiety, depression
Autonomy- still dependent -on whom?
Self actualisation- SUD can delay developmental process

9. Why people use drugs
Reasons- curiosity, media, pos reinforcement, enhance sensations, increase psychophysical performance, social pressure, peer association & youth culture,
After first try, other times may be a lot easier- pos reinforcemnet
Drug use may be statistical ‘normal’ in some micro-communities
‘normalised’ in peer group-access & acceptable
Cannabis ‘not a drug’ view- denial of risk
Social acceptance of cocaine use increased
Trans-generational SUD- heroin even!
Adolescent factors- Bobby has covered

10. Why treat?
‘Normal for adolescents’?- rebellion, peer involvement, individuating, experimentation- BUT….adult addiction starts in adolescence.
SUD has ‘epidemic character’ in adolescence
Critical time – development, social & emotional learning, education & employment.
Co-morbidity , psychosocial damage, criminality, trans-generational prevention.
What can we prevent now- (Harrison 2001) – while ¼ remain clean, Rx does reduce overall use, symptoms, criminality, emotional distress

11. More reasons to treat!
COST-EFFECTIVE- Godfrey UK study- for every £1 invested in Rx, save between £9-18. Looked at settings from Tier 1 to Tier 4.
Keating- $7 return for every $1 spent.
Crime- proposed link to 29% drop in crime in Dublin area due to increased MMT
Hospital visits- alcohol, heroin, prescription drugs, injury, overdose- heroin related to more ‘all cause’ visits over time ( Tait 2002)
Keating D, Hertzmann C, (1999) – developmental health and the wealth of Nations. Social, Biological and Educational Dynamics.
New York- Guildford press. $7 return for every $1 spent- greatest return when spent in most deprived sectors of the population.

12. Treatment needs of young people
Needs may pre-date, worsen with or be a consequence of drug use.
CRAVINGS, VIRAL STATUS, OVERDOSE RISK,
ABCSCESSES, TRAUMA, DEPRESSION, ANXIETY,ADHD
biological
HUNGER
COLD
COPING /LIFE SKILLS, DEPRESSION, ANXIETY,
SELF HARM,
PSYCHOSIS,
MOTIVATION , TRAUMA,
ANGER, CONCENTRATION
EMOTIONAL DYSREGULATION
ACCOMODATION, BENEFITS,
FAMILY ACCESS,
DOMESTIC VIOLENCE,
LEGAL ISSUES, EMPLOYMENT,
SCHOOL, SEXUALITY
social
psychological

13. Response to treatment needs
medical /surgical Rx/ Medication
Substitution Rx
Needle exchange
Viral Screening
MULTI-AGENCY
PARTNERSHIP
WORKING
biological
Screening & education
Functional analysis
Counselling
Brief MI
CBT
Family therapy
Young Person
Liaison with SW, probation, childcare, family, contraceptive advice
psychological
social
Information

14. Service development
Core aspiration- young people will use us! i.e., engagement & retention
Current best practice, evidence based, accessible.
Respect dignity, ethnicity, language, culture.
Non-complex presentation of information .
Information- how to get help, drugs, feelings, sexual matters, day activities, training, family.
Policies & rules-client & staff safety, legal framework- police, probation, courts.
Confidentiality- not absolute-child protection.
Transitional care plan for before their eighteenth birthday.

15. Service delivery
Listen to what young people tell us- try to develop services that they will engage with.
Careful common assessment, information sharing, multi-agency working. Multi-system intervention
Increase accessibility- self help programmes, drop in centres, OP access, day Rx centres.
Information based intervention is suitable for Tier 1. Peer support and advice. Can be delivered in schools and youth groups also.
Support & education for Tier 1 & 2 from Tier 3. Referral pathways clarified.
NEED TO INVOLVE FAMILY IF POSSIBLE.
Reform delivery & strengthen accountability-prevention & early intervention-drug misuse assessments to be part of all services- build service & workforce capacity. NTA Essential Elements document June 2005.

16. 4 TIER MODEL
Tier 1- No specialist skills in either adolescent MH or Addiction. Any professional working with young person.
Tier 2- specialist skills in one of addiction or adolescent
Tier 3- specialist skills in both areas. New developing service.
Tier 4- specialist skills in both, and an inpatient / day hospital service.
HAS integrated care pathways- common assessment framework & avoid duplication- information sharing, multi-agency partnership working. Will develop KPI’s and aim to prioritise high risk / vulnerable groups. Mainstream services should remain in contact and often be the co-ordinators.

17. 4 TIER MODEL CAMH-child & adolescent mental health/ CAA- child & adol
4 TIER MODEL CAMH-child & adolescent mental health/ CAA- child & adol. addiction
Tier level
Specialist skills available to help young drug users
Type of adolescent accessing service
Type of intervention for drug use
Intervention delivered by
Examples of such services
Intensity and duration
NOT either CAMH or CAA
Start of drug use
Basic advice +/- referral
Individual professional
Teacher, SW, GP, A&E, PO
Low intensity-
ongoing
Either CAMH or CAA
Problems due to drug use
Basic counselling, brief intervention, harm reduction
Individual or MDT
CAMHS, Addiction DTF,
Medium intensity-
Medium duration
Both CAMH & CAA based in the community
Substantial problems due to drug use
Specialist counselling, family therapy, medication
Specialist MDT in adolescent addiction
Specialist adolescent addiction service
Hi- intensity,
Short / medium/ long term
CAMH & CAA at In-Patient / Day hospital
Severe problems or drug dependence
Individual & family therapy medication, residential- detox / stabilise
specialist MDT in adolescent addiction
Specialist day hospital or in-patient adol. Addiction
Very high intensity ,
Short/
medium/ long term
Tier 1
Tier 2
Multi-agency working. Clear guidelines and role definitions. YOT, CAMHS, Looked after children- responsibilities remain, but greater wrap around care possible. Secondment a good learning opportunity. Tier 1-To ensure universal access, continuity of care. Identify those at risk. Tier2- reduce risks, reintegrate. Tier 3- deal with complex and multiple needs, reintegrate. Tier 4- for high intensity for high risk- medication, residential, MDT daily access.
Tier 3
Tier 4

18. Tier 4 service thus far..
Tier 4 team – Project manager, key workers, nurses, counsellors, family therapist, SW, psychologist, doctors.
Complementary- Artwork, Reiki, Music
Token economy, card system, contingency mx, careplanning, case review, keyworker.
Offer intensive day hospital /residential.

19. ROLE OF KEYWORKER ‘The link’ between young person & service
Co-ordinator / advocate / educator / identifier of resources / engager
Frequent positive contact & support
Monitor drug use & progress
Facilitate engagement with family & team
Limited outreach capacity
Contact, connection, care.

20. Tier 3,2,1 service
MDT Tier 3- two being developed in the community in Dublin.
Multidisciplinary- core competency mix
Local accessibility and integration
Adaptable- offer brief early intervention
Education and advice supportive role
Multi-agency Tiers 1 & 2- some already in place, others in need of development.

21. YPP urinalysis results over past 3 years

22. Ready to stop?

23. How do we approach a session?
Each is still a young person, and deserves culturally appropriate respect as a person. Generally, the process is as for any other.
Ensure the reason for and process of the assessment are explained.
Drug issues need not be the first topic.
If intoxicated, can ask advice of a colleague.
If threatening, ask advice of colleague, and do not continue session. This is not common!
Make the YP feel ‘it is about you & for you’.
Capitalise on existing relationships, understanding the young person & continuing interpersonal relationships will strengthen care pathways. Holistic assessment. Joint assessment. Invite family, invite other agencies if appropriate, but make the YP feel that you listen to Him/Her !

24. Questions to ask re: drug use
Age at first use?
Which drugs tried
When started using on daily basis
Method of taking – po, intranasal, IVDA
Weekly /daily pattern
Go thro’ each drug
What it does for you?
How much it costs
How they pay for it
Knowledge re: risks of drug use- effects of drugs, IVDA risk, sexual
Forensic history
Effect on friends & family
Family history-context

25. Symptoms and ASUD Paranoid thoughts Delusions Hallucinations
Thought disorder
Concentration
Motivation
Behaviour change
Speech, affect
Depression / Mania
Anxiety
Restlessness
Appetite, energy
Skin, nose, eyes
Unexplained weight loss
Self care, strange

26. Co-morbidity/ dual diagnosis
More violence, suicidal behaviour, service costs and poor Rx outcome in both populations.
Increased threshold for entry to both services.
2003-UK. CMHT- 44% reported drug/harmful alcohol use. (adult)
In addiction services- anxiety & depression both near 30%.Personality disorders common. Psychosis 10%.
Poor coping, relationship problems, hopeless.
DD-adolescent- 31% had psych.visit – 54% with prior Dx visited- girls & internalisers more likely -Sterling SF 2005
High rates of depression, anxiety, eating dis, ADHD, CD.

27. Early age alcohol consumption
Adolescent alcohol- 1% A/E admissions, 50% trauma admissions for that age group
Underage drinking in unsupervised locations
Aggression, violence, accidents and trauma
Road traffic accidents- young men especially.
DSH, depression, anxiety, PTSD , ADHD(CD).
Alcohol problems are more predictive of suicidal behaviour in males.

28. Sexual risks Early menarche- more smoking & drinking
Disinhibition, reduced recall and self-awareness
Sex for drugs, sex work
STIs and early pregnancy
Sexual / contraception knowledge
Condom negotiation skills

29. Profile of Pregnant Drug User
Single & Poor
Unemployed
Unskilled
Lack child care facilities
Suffered trauma
Poor parenting skills or confidence
Increased stigma when pregnant
Fear / suspicion of services
Poor nutrition & dental care
Infectious disease risk
50% have partner using

30. Treatment Aims (Day, 2003) Practical & emotional support offered
Ante- and post-natal use of multiple services- obstetric, medical, addiction, SS.
Early booking appt. ensures safety & allows education re: care and benefits
Promotion of child welfare
Period of engagement is for duration of pregnancy and beyond, including advice re: family planning.

31. Forensic association
Crime association- may share same risk factors only.
predictive dose-response relationships in both directions.
Violence, vandalism, fraud ~ adolescent drug use
Theft not only assoc. with drug use. Peer behaviour & prior forensic hx also determine crime (Hammersley).
Criminality reduces after residential Rx.
High rate of SUD in prison population- all should be screened-Audit Commision UK & others
Polydrug use ~90% boys .
Studies- Howard 1990, Pottieger 1991, Hagell 1994, Misspent youth (audit commission 1996), Williamson 1996, Collinson ’94,’96- all found high drug use – most in the 90% reange, and mostly polydrug use. Boys more than girls, - crime & drug use studied by Hammersley in Scotland &

32. Drug offence prosecutions for U-17s by gender, 1995-2004.

33. Homeless – vicious cycle
Family breakdown & drug / alcohol use.
SUD can exclude from a/c- many young
Predictors- peer & family drug use & attitudes, psychological well-being
Very difficult to engage- often hx of care
Safety- violence, sexual violence, adult manipulation, criminality
Treatment access after leaving prison

34. Early School- leaving Many leave school early- < 14.
Link in with delinquent peer group.
1/10 no qualifications, 1/5 no Leaving Cert.
Effects of drug use- poor school performance, lose positive peer group and social skills enhancement.
ESPAD figures. Comiskey & Miller 2000.
Polydrug use.

35. Adolescent drug users - different from adults at presentation
Less dependence evident
Binge pattern more common
Intoxication effects prominent
Often reluctant patients, hence ENGAGEMENT a big issue- this can be over months.
Peer influence greater- family support vital.
Rehabilitation- creative thinking required.
Harm reduction is the overall aim- includes abstinence & stabilisation.

36. THANK YOU!
Un Convention on the Rights of the Child Article 33 of UN CRC –
‘States parties shall take all appropriate measures, including legislative, administrative, social and educational measures, to protect children from the illicit use of narcotic drugs and psychotropic substances as defined in the relevant international treaties, and to prevent the use of children in the illicit production and trafficking of such substances.’